Quote Originally Posted by mdunn View Post
If the patient comes in to the hospital with cough, congestion, and shortness of breath and the H&P states acute bronchitis but the discharge summary states asthmatic bronchitis, would it be appropriate to code asthmatic bronchitis 493.90 or asthmatic bronchitis w/acute exacerbation 493.92, or should the doc be queried? The patient was treated with antibiotics and inhalers.
i would either wait to read the dictation, or yes. query the doctor.